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H1N1 flu pandemic could stress Vero health system
BY LISA ZAHNER - 32963 STAFF WRITER & ROB STEIN - WASHINGTON POST (Week of September 17, 2009)

Even if swine flu remains a mild infection, the pandemic could be the tipping point for an emergency medical system teetering on the edge.

“The worry is, the health-care delivery system could be overwhelmed by people who are sick or think they are sick,” said Kim Elliott of Trust for America’s Health, a nonpartisan think tank and advocacy group.

John King, director of the Indian River County Emergency Services, said paramedics currently are responding to about 10 percent more calls per day than usual from patients displaying “flu-like symptoms” bad enough to dial 911.

Since the first of August through this past weekend, 73 people have been transported to the Indian River Medical Center Emergency Room complaining of the flu – a 2,400 percent increase over the three patients who came with the flu during the same period a year ago.

While none of the 73 needed hospitalization, the swine flu virus, also known as H1N1, could ultimately infect up to half the U.S. population, making as many as 700 to 800 Vero Beach residents sick enough to require hospital admission, with as many as 130 of these needing intensive care, according to a presidential advisory council estimate.

The Indian River Medical Center’s Intensive Care Unit has beds for 20 adult patients. The pressure on local hospitals may be even greater assuming the population of Indian River County swells with snowbirds – as it usually does — in late October or November, about the same time that flu cases are expected to spike.

“We have 44 beds in the Emergency Department, so we could take up to 53 patients in beds in the ED,” said Betsy Whisman, a hospital spokesperson. “We also have a plan that would evaluate, manage and treat flu patients who can return home in triage rooms.

“If more space would be needed, we would use our Minor Care area. If even more space were needed, we would rent an air conditioned tent and evaluate patients outside of the ED,” Whisman said. According to Eric Toner of the University of Pittsburgh’s Center for Biosecurity, “there will be millions and millions of people seeking care in a relatively short period of time,” noting that the nation has only about 85,000 critical-care beds.

“Only a small percentage of those people will require hospitalization and a small percentage will require intensive care. But it’s still an awful lot of people.”

Whisman, who noted the Vero Beach hospital’s occupancy level is currently 82 percent, said available beds for flu patients would be “whatever is open at a given time.

“We do not have a finite number of beds set aside for flu patients so it would change on a daily basis,” she said. “If we had the need to admit many patients with the flu, we could try to place them on one unit, but these patients could also be cared for in patient rooms using proper isolation techniques.”

Because H1N1 disproportionately affects children, experts worry about the system’s ability to handle a large number of pediatric patients. Many facilities do not typically stock medical equipment such as breathing tubes and intravenous tubes for children.

“Kids come in all shapes and sizes,” said Joseph L. Wright of the American Academy of Pediatrics. “What could be real disaster is if you don’t have equipment to fit the kid in front of you.”

The hospital’s Whisman said the Indian River Medical Center has four pediatric beds normally, but could handle up to 10 pediatric flu victims if needed.

“If a child was critically ill or potentially critically ill we would transfer him or her to a pediatric center like Arnold Palmer’s Children’s Hospital in Orlando or St. Mary’s in West Palm Beach,” Whisman said.

Even though scientists recently reported that the vaccine that has been developed to protect against H1N1 flu appears to work much better than hoped, the second wave of U.S. infections is expected to peak in October — well before the shots become widely available.

The first shipments of the H1N1 vaccines are expected to arrive in Vero around the end of October and those will be metered out to high-risk groups and healthcare workers, who will have greater exposure to infected people.

Additional shipments are expected each week, but local public health officials are unable to even make the broadest estimate on how many doses will be allocated to Indian River County. It is also unclear whether people will need two doses of the vaccine or just one, as that’s still being determined as part of the clinical trials.

Perhaps the most amazing thing to many local officials is that the number of swine flu cases in Vero Beach is no longer being tracked or reported – so we have no hard data on whether a crisis is developing, and if so, how rapidly.

Miranda Swanson, administrator of the Indian River County Health Department, said everyone seeking medical help with flu-like symptoms is being treated on the assumption that they have swine flu.

“We’re not requiring physicians to report cases to the CDC because with H1N1, we know this is widespread,” Swanson said.

What is being tracked to determine the severity of the flu in various regions is the number of people actually admitted to the hospital, not just treated in the emergency room, and the number of people who have died from the flu. Those numbers for Indian River County thus far are zero.

“For overall influenza activity, we rely on data from the sentinel physicians,” Swanson said.

Indian River County has six sentinel physicians. Five of those are employed by the Florida Department of Health and work at the Indian River County Health Department Vero Beach and Gifford clinics. Only one sentinel physician, Dr. Dennis Saver, is in private practice and he is also in Vero Beach.

The statistics from the sentinel physicians Swanson refers to are about two weeks old when local public health officials receive the data.

On Friday, Sept. 11, Swanson received a report for flu data for the week of Aug. 23-29, and the numbers on the report were only the numbers of patients actually tested by a physician, so it underestimates the numbers, as many patients are not being tested for flu anymore because it’s so “widespread.”

This raises the question as to how useful this data is for practical, on-theground management of the disease.

The U.S. Centers for Disease Control and Prevention uses a system called the Pandemic Severity Index to determine what recommendations to make to local healthcare providers, schools, and governments.

There are five categories in the system, which progress in ascending order of severity, similar to hurricanes. The CDC region in which Florida is contained is currently at a Category 2 status, based on hospitalizations and deaths related to positively tested cases of the H1N1 flu virus.

Should conditions in Indian River County or on the Treasure Coast indicate a more severe outbreak of H1N1, local health officials do not have the authority to adjust our area up to a Category 3 status. Swanson said that kind of directive would have to come from the CDC, in response to the data being tracked.

Currently, under a Category 2, recommendations include vigilant hand washing, sneezing into the sleeve instead of hands, using hand sanitizer, going home or staying home if sick and self-isolation of sick people to recover from home.

Should the flu ramp up to a Category 3 on the Pandemic Severity Index, Swanson said the Health Department would recommend the following strategies:

* Permit high-risk staff and students to stay home;
* Increase social distances between children;
* Actively screen students and staff for fever and other symptoms of flu;
* Encourage children with ill household members to stay home;
* Extend the time that ill people stay home from the current 24 hours after fever resolves without benefit of fever reducing medicine to 7 days;
* Close early childhood program as a last resort, and balance the risks of flu in the community with disruption it would cause.
* Close schools as a last resort, balancing the disruption dismissals would cause in both education and the wider community.

Swanson said the Health Department “would also look at other actions to increase social distancing, such as looking at limiting public gatherings, decreasing the number of social contacts, increasing distances between persons, and modification of workplace schedules and practices.”

These measures could affect attendance at local theatres, concerts and festivals, as well as participation in social events, which are the lifeblood of Indian River County’s nonprofit organizations.

As Vero Beach prepares to deal with the impending crisis, the federal government is sending $350 million to state and local governments, including $90 million to help the nation’s 4,897 hospitals and 3,829 emergency rooms prepare.

In addition, the Strategic National Stockpile has more than 116 million masks, more than 52 million doses of antiviral drugs and 4,500 ventilators.

Federal officials have also begun to count available ventilators, which could be crucial in caring for the sickest patients.

Experts say they expect the virus to linger longer this fall and winter, raising deep concern about whether the stockpiles of supplies, the contingency plans to improvise extra beds and backup plans to call up reserves of doctors, nurses and other health-care workers will be sufficient.

Already in Indian River County, not everyone is being prescribed drugs like Tamiflu when they show up at a doctor’s office or the Health Department.

Doctors are trying to prevent the H1N1 virus from developing resistance to the handful of drugs they have in their toolbox to fight the flu, so they’re reserving the drug for people who are very ill or who have conditions such as heart disease or lung disease, which may cause them to develop complications from the flu.

A course of Tamiflu also costs about $140, which is a barrier to some people who are sick, even if they have insurance.

The first line of defense will be to persuade those with mild symptoms to stay home to minimize the spread of the virus, and to make sure those who really need care receive it, while still providing treatment for the usual number of heart attack, gunshot and accident victims.

“It is hoped that patients will remain home, as advised, if they have mild to moderate symptoms and call their primary care physician,” said the hospital’s Whisman. “This will help prevent exposure of other people and patients.”

One group already grappling with how to deal with the onset of the H1N1 pandemic is employers.

The Indian River County government, which employs almost 900 people, is in some ways typical of large employers.

Human Resources Director James Sexton issued a memo to county employees notifying them that they would be sent home from work if displaying flulike symptoms and would be expected to stay home until they were better.

Sexton said employees are concerned about getting the swine flu and want their co-workers to stay home if they’re sick.

“I have people calling my office complaining that the guy in the next cubicle is coughing, so then I get on the phone with that department head or supervisor and they have to make the person go home,” he said.

Sexton said this has puts his staff and his department heads in the “awkward position of playing doctor” on a daily basis.

Fortunately for county workers and employees of large companies, most have benefits such as sick days so being sent home is not taking money out of their pocket.

But small businesses and their employees are in a more precarious position. Many employers can’t afford to be without key employees for a week, and employees of small businesses may have neither insurance nor sick days available.

If the sick person is a child, that also could mean the need for a parent to stay home with that child for seven days while trying not to get sick themselves. In many family financial situations, an unplanned, unfunded seven- to 10-day “vacation” from work to nurse a child with the swine flu is a real hardship.

So how is the Indian River School District preparing to deal with the pandemic? Are some schools already feeling the effects of swine flu to a greater extent than others? How many students were out last week with swine flu?

Incredibly, the school district does not seem to have much hard data, and was unresponsive to our requests for information.

Vero Beach 32963 was told, in fact, that its reporter could not speak directly to the official who is in charge of coordinating health efforts for the district, that all information had to come through Public Information Officer Patty Vasquez.

When we requested absentee numbers of students and teachers out with the flu, we were told in an email by Vasquez that “we don’t collect numbers for students that are absent due to flu or flu-like symptoms because we don’t require parents to tell us why they are being kept home. We do keep track of students who are sent home from school with “flu-like” symptoms.”

“The stats that we do collect would not give you any kind of picture of the number of school age children with the flu, because we don’t know for sure whether or not they actually have the flu,” she said. “They are sent home with flu-like symptoms, based upon an assessment by our Health Assistants.”

When asked for the number of children being sent home sick, the figure finally provided was “less than one percent” of the public school enrollment.

Vasquez said each school sends figures on gross absenteeism and the numbers of students and teachers sent home sick to the Health Department, but when asked whether or not each principal reviews the figures daily or whether School Superintendent Dr. Harry LaCava reviews district-wide figures daily, Vasquez replied:

“Principals are staying on top of the situations in their schools. Dr. La Cava does not review the numbers daily. He has staff to do that.”